Provider Demographics
NPI:1184692014
Name:WYATT, MARK ANDREW (DC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ANDREW
Last Name:WYATT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2106A TRENTON RD
Mailing Address - Street 2:DR MARK A WYATT
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-1609
Mailing Address - Country:US
Mailing Address - Phone:931-647-7677
Mailing Address - Fax:931-647-0122
Practice Address - Street 1:2106A TRENTON RD
Practice Address - Street 2:WYATT FAMILY CHIROPRACTIC
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-1609
Practice Address - Country:US
Practice Address - Phone:931-647-7677
Practice Address - Fax:931-647-0122
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2098111N00000X
TNDC0000002098111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
V08814Medicare UPIN